Myofascial Pain: What is the Best Treatment?

Myofascial pain is generally described as a taut or hard band within a muscle, with tenderness and referred pain that can be present either locally, regionally, or “secondary” to some other condition. Myofascial pain is estimated to affect approximately 44 million Americans.1 Recent studies have identified a myofascial component of pain in 30% of patients in an internal medicine practice, 55% of those in a head and neck pain clinic, and up to 85% to 95% of cases in a pain center.2-5

Although the exact mechanism is not fully understood, myofascial pain syndrome (MPS) is characterized primarily by the development of trigger points. These trigger points are found within the muscle, fascia, or tendinous insertions and are diagnosed routinely by palpation.6

Of some interest is the variation in myofascial pain, and inflammation in general, in relation to hormones—specifically, the menstrual cycle. In a study by Dao et al, women on oral contraceptives were more likely to remain in pain throughout the menstrual cycle, whereas women not taking contraceptive had peaks of pain alternating frequently with pain-free periods.7 Thus, it appears that oral contraceptives actually increase the frequency of myofascial pain in women.

The link between myofascial pain and psychosocial factors can be complex and not fully appreciated by clinicians, as evidenced by the literature. For example, Schwartz et al used Minnesota Multiphasic Personality Inventory (MMPI) profiles to compare 42 successfully treated myofascial pain patients with 42 unsuccessfully treated women with myofascial dysfunction.

In both groups, the deviation from normal was diagnostic of a “psychophysiological disorder marked by repression and somatization,” even though the unsuccessfully treated patients had a significantly higher dysfunction on the MMPI.8 In a separate study, individuals with a history of endometriosis had a much higher proportion of hyper-sensitization and myofascial trigger points than the general population.9

Table 1 lists a number of contributing factors for the development of myofascial pain. One contributing factor to the cause of myofascial pain is smoking. In a study of 529 patients with masticatory myofascial pain, 32% were smokers and they had a much higher pain severity and a higher frequency of sleep disturbances and psychological distress than nonsmokers.10

Differential Diagnosis

Differentiating myofascial pain from other pain conditions can be challenging and must include the possible diagnosis of fibromyalgia. The American College of Rheumatology (ACR) reports that fibromyalgia affects between 2% and 4% of individuals, primarily women. Reviewing scores of articles on this subject, it appears that even making the diagnosis is a challenge to many physicians. The issue is further clouded by the fact that the ACR has changed the basic diagnostic criteria for fibromyalgia over the years. (See Diagnosing Fibromyalgia).

In his seminal article, Gerwin said that when the myofascial pain syndrome becomes chronic, it tends to become more generalized but “does not change to fibromyalgia”—which is characterized by multiple tender points throughout the body. 11 Indeed, Bohr noted that active trigger points were found in only 18% of patients with myofascial pain, leading him to conclude that “different therapists are unable to reliably determine when a trigger point is present in a patient with low back pain.”12

Trigger Points

Trigger points are most commonly characterized by two primary and two secondary features (Table 2).13,14 Although trigger points are usually differentiated from tender points, there are some suggestions that both are part of one clinical spectrum. The major reported difference is that trigger points produce pain in a referred pattern, whereas tender points generate pain at the site of palpation.15 Trigger points are further classified as active versus latent. Latent trigger points elicit painful sensation only with the application of direct compression. Active trigger points elicit pain spontaneously as well as with compression.16

The link between—and confusion regarding—myofascial pain and fibromyalgia has been longstanding. In one of the more interesting studies on fibromyalgia and myofascial pain syndrome, the authors had 4 experts on myofascial pain and 4 experts on fibromyalgia each examine 3 groups of patients—those diagnosed with fibromyalgia, those with myofascial pain, and 8 healthy individuals. All physicians were blinded as to the diagnosis.

In both disease groups, local tenderness was common (65% to 82%), but interestingly, the myofascial pain experts found it more frequently—in 82%. Active trigger points were found in 18% of examinations of patients with fibromyalgia and myofascial pain, but “latent trigger points were rare in all groups.” When a “more liberal definition of trigger points” was used, 23% to 38% of the patients with either fibromyalgia or myofascial pain were positive. There were considerable problems with reliability and the authors concluded that there is no consistency among experts in 23% to 38% of patients. In other words, all fibromyalgia patients have some myofascial pain, but not all myofascial pain patients have fibromyalgia!17

Myofacial Pain Treatment

Dry Needling

The traditional treatment of myofascial pain, as originally recommended by Janet G. Travell, MD, the creator of the term myofascial pain syndrome, has been dry needling.18 Although there have been negative papers on the effectiveness of dry needling, there are far more papers indicating a very pronounced response, especially when heat is added to the dry needling.19,20 In 41 patients with upper trapezius myofascial pain, dry needling once a week for 3 weeks resulted in a significant decrease in pain (P < 0.001). Moreover, the reduction in pain was associated with improved mood, function, and level of disability.21

More recently, investigators have studied the use of dry needling combined with other therapeutic modalities. In one study, researchers compared superficial dry needling combined with active stretching to stretching alone. The investigators found that dry needling plus stretching was significantly more effective (P = 0 .043).22 The authors wrote: “Dry needling followed by active stretching is more effective than stretching alone in deactivating trigger points (reducing their sensitivity to pressure), and more effective than no treatment in reducing subjective pain. Stretching without prior deactivation may increase trigger point sensitivity.”

In a study of 138 men with chronic prostatitis and chronic pelvic pain syndrome, myofascial trigger point assessment and release therapy was found less effective than myofascial trigger point assessment and release therapy combined with relaxation therapy (RT).23 More than half of patients treated with the myofascial trigger point assessment and release therapy/RT protocol had a 25% or greater decrease in pain and urinary symptom scores, noted the researchers. In those at the 50% or greater improvement level, median scores decreased 69% and 80% for pain and urinary symptoms, respectively.23

In another study of myofascial pain of the jaw muscles, the effect of dry needling in classically recognized acupuncture points was compared with dry needling in skin areas not recognized as acupuncture points, or so-called sham acupuncture. Essentially no difference was found between sham acupuncture or specific acupuncture dry needling—both groups improved.24 The authors concluded that “both acupuncture and sham acupuncture reduced pain evoked by mechanical stimulation of the masseter muscles in myofascial pain patients. However, this reduction in pain was not dependent on whether the needling was performed in standard acupuncture points or in other areas of the skin. These results suggest that pain reduction resulting from a noxious stimulus (ie, needling) may not be specific to the location of the stimulus as predicted by the classical acupuncture literature.”24

Electromedicine

Other methods to “release” myofascial trigger points have been studied, including therapeutic ultrasound, laser therapy, and transcutaneous electrical nerve stimulation (TENS). Therapeutic ultrasound, with and without muscle and myofascial stretching, has been reported to be more successful than muscle stretching alone.25 An earlier study had found that 5 consecutive days of anodal transcranial direct current stimulation (tDCS; 1 mA anodal over M1 for 20 minutes) combined with standard stretching was significantly more effective than sham stimulation for shoulder passive range of motion.26

In another study, continuous ultrasound (3 MHz, 1 W/cm), pulsed ultrasound (3 MHz, 1 W/cm, 1:1 ratio), and sham treatments were compared. All three groups had significant improvements in all of the pain scores, the severity of muscle spasms, function assessments, and certain sub-parameters of the quality of life scale (P < 0.05). The continuous ultrasound group had significantly greater improvements in pain at rest (P < 0.05). However, no statistically significant differences were observed in the other parameters (P > 0.05).27

Gur et al compared low-level laser therapy with placebo, used daily for 2 weeks (except weekends). The active laser group showed significantly greater improvement.28 TENS also has been widely used in the treatment of both fibromyalgia and myofascial pain, with considerable relief of pain (high intensity TENS; 100 Hz, 250 msec) and pain reduction (lower intensity TENS; 2 Hz, 250 msec) in a study by Graff-Radford et al.29 The results suggest that “high-frequency, high-intensity TENS is effective in reducing myofascial pain.” Despite these findings, TENS “did not reflect changes in local trigger point sensitivity,” the authors concluded.

Physical Therapy and Message

One study evaluated patients who received 6 sessions of physical therapy, with half of the group taught a combination of self-massage and home exercise. The patients in the combination group had a significantly greater improvement in pain than those who did not do the self-massage and exercise at home.30

In a review of 10 different studies assessing the effects of massage on fibromyalgia, myofascial release had significantly positive effects on pain and “medium effects on anxiety and depression in contrast with placebo.” Myofascial release improved pain, stiffness and quality of life. Connective tissue massage improved depression and quality of life, and manual lymphatic massage was superior to connective tissue massage. Shiatsu massage also improved pain, pressure pain threshold, fatigue, sleep and quality of life; however, Swedish massage did not improve any of those clinical outcomes.31

Medical Therapy

Local anesthetics have also been used in what is sometimes called wet needling in both fibromyalgia and myofascial pain, with studies showing improvements in pain ratings. In one comparative study, patients with myofascial pain were compared with fibromyalgia patients after trigger point injections with a local analgesic (0.5% xylocaine).32 In a comparison of the two groups, the immediate effectiveness of injection was significantly less (P < 0.05) in the fibromyalgia group than in the myofascial pain group based on three clinical endpoints: pain intensity, pain threshold, and range of motion. Two weeks after injection, both groups showed significant improvement (P < 0.05) in all three parameters as compared with preinjection measurements. However, patients with fibromyalgia had significantly more post-injection soreness for longer periods of time than those with myofascial pain.32

In another comparative study, 29 patients with myofascial pain were randomly assigned to one of three treatment groups: lidocaine injections (0.5% lidocaine), dry needling, or onabotulinumtoxinA (Botox; 10-20 IU in each trigger point) injections, followed by stretching of the muscle groups involved.33 The patients were instructed to continue their home exercise programs. Pain pressure thresholds and pain scores significantly improved in all three groups. In the lidocaine group, pain pressure threshold values were significantly higher than in the dry needle group, and pain scores were significantly lower than in both the onabotulinumtoxinA and dry needle groups. In all, visual analog scores significantly decreased in the lidocaine injection and onabotulinumtoxinA groups and did not significantly change in the dry needle group. The authors concluded that lidocaine was considerably more effective than dry needling or onabotulinumtoxinA injections.33

In one study of the benzodiazepine clonazepam (Klonopin) in patients with temporomandibular disorder with myofascial pain, patients who had been unresponsive to occlusal splint, behavior, and physical therapy were found to achieve some greater response to clonazepam. However, there is a significant question about the possible side effects of depression and liver dysfunction.34

Complementary and Alternative Therapies

The use of music has also been studied in patients with fibromyalgia. A group of 120 patients were divided into 4 groups: 1) patients listened to music by Bach, 2) patients were treated with vibratory stimuli on a combination of acupuncture points; 3) patients had both the music and vibratory sensation with the inclusion of binaural beats; and 4) patients received no stimulation. All 4 groups showed a significant improvement; however, the greatest reduction of pain was in those who received a combination of music therapy and vibration. The fact that the untreated group showed improvement suggests a “placebo effect.”35

Mindfulness training may also be helpful for patient with myofascial pain. In one study, mindfulness training was given for 7 weeks to a group of fibromyalgia patients. These patients reported a significant decrease from baseline in anger, anxiety, and depression. This improvement in mood was maintained for approximately 3 months.36

In both fibromyalgia and myofascial pain, magnesium deficiency is common and magnesium replacement therapy should be considered.37

Conclusion

Fibromyalgia is far more difficult to diagnose and treat than myofascial pain. In general, it appears that the longstanding use of dry needling, especially with added heat, may be as effective as most of the newer approaches. Local injections of anesthetics, laser, and TENS would be the next potential approaches. Laser may be used as a third level of treatment.

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